The evolution of psychosocial care in cancer centers

The American College of Surgeons Commission of Cancer Accreditation for Accreditation of Community Cancer Centers (ACCC) will mandate that all centers must have a psychosocial program that identifies patients with distress and triages them to appropriate care in 2015. “But how can we move from establishing a new standard to implementing it in routine clinical care?” asks Jimmie Holland, MD, of Memorial Sloan Kettering Cancer Center in New York, New York, at the 2014 NCONN Conference in Atlanta, Georgia. Nurse navigation has a key role in this evolution of the clinical care of patients with cancer.

Historically, a diagnosis of cancer was equivalent to death. Often, physicians did not reveal a diagnosis to patients because of fear of a disease with no known cause or cure; the patient would give up hope. Attitudes in the first half of the 20th century produced a social stigma about cancer similar to that of mental illness, psychiatric or psychological problems, and emotional problems. Those patients who did know their diagnosis kept it to themselves.

The silence started to end in the mid-1970s as physicians began telling patients of their diagnosis and treatment options. Psychological responses to a cancer diagnosis and its treatment options could finally be explored. This was the beginning of the science of psychosocial care. But psychological issues were considered to be soft science, and data based on patient self-report was deemed unmeasurable and unreliable.

The first major effort was to develop valid and quantitative tools for measuring subjective symptoms such as health-related quality of life, pain, fatigue, anxiety, depression, and delirium. The tools enabled researchers to conduct controlled clinical trials on interventions. But other barriers hindered development of psychosocial services, such as physician-related beliefs (“It's a Pandora's box—how will I turn it off?” “Patients will tell me when they're upset.”) and patient-related attitudes (“I'm too embarrassed to tell the doctor.” “These are real problems—talking won't help.”). In addition, the cancer care setting is often an overly busy office or clinic. Patient's psychosocial problems received little attention even though clinically significant distress was documented in one-third of patients with cancer.

The National Comprehensive Cancer Network (NCCN) appointed a multidisciplinary panel to address this situation. The panel worked to find a more acceptable term for the emotional toll of cancer that would reduce the associated stigma. The term they chose was distress. It is less stigmatizing than psychiatric, psychosocial, or emotional; easier to bring into routine care; and encompasses psychological, social, and spiritual concerns.

The NCCN Distress Management Standard of Care and Clinical Practice Guidelines define a process that prompts recognition, monitoring, documentation, and treatment of distress at the initial visit. Distress should be recognized, monitored, and treated at the first visit, and screening should identify the type and level of distress. A tool was needed to identify distress. The panel chose to follow the model of the successful pain-management approach of patient-report “on a scale of 0 to 10,” and distress screening could now be incorporated into a patient assessment as a sixth vital sign.

The Institute of Medicine report A New Standard of Quality Cancer Care: 2008 states the psychosocial domain must be integrated into routine cancer care. Nurse navigators current tasks are to assure that new standards become a part of routine care. Working with ACCC and community cancer centers, they can encourage the widespread use of screening and triage to ensure patients receive comprehensive cancer care.